NCC201248_NOI Application_20200327

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/26/2020 3:35:32 PM (NCG01 NOI Submission)
Approve by Clark, Paul 3/26/2020 4:11:06 PM (Review- Construction NOI 23698)
• The task was assigned to Clark, Paul by round robin distribution 3/26/2020 3:36 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 30, 2020 5:00
PM 3/26/2020 3:36 PM
Submit by McCoy, Suzanne 3/27/2020 4:51:23 PM (Payment Verification for NCC201248)
* Richard Baker
• McCoy, Suzanne assigned the task to McCoy, Suzanne 3/27/2020 4:50 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 7, 2020 5:00 PM
3/26/2020 4:11 PM

.• SThF� ';
1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Circle K - NTI NC 42 Garner - NC.84
1 b. Specific Lot This field may be used to list specifc lot nunbers.
Numbers
2. County* Johnston
3. Highway or Street 5771 NC Highway 42
Address* Street narre only is acceptable if no address nunber assigned yet
4. CityorTownship* Garner
5. State * NC
6. Zip Code* 27529
7. Latitude* Enter the latitude in decinal degrees
35.6013
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-78.5734
If you do not know the latitude and longitude coordinates for this project, you can search the location on this map of
North Carolina. Look for the coordinates in the bottom left corner.
9. Date to Begin*
05/04/2020
Estirrated Construction Project Start Date
10. Date to End *
05/02/2022
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Developrrent
12. Acres to be
2.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.83
(acres)*
14. Post- 1.11
construction (Estirrated)
impervious area
(acres) *

NCC Project NCC-JOHNS-2020-Circle K - NTI NC 42 Garner - NC.84
Tracking ID Assigned autorratically
Below you must enter waterbody information for surface waters affected by this project. Please consult
DWR's Surface Water Classifications Map Viewer to find waterbody name and corresponding index number. Please
enter only immediate receiving waterbodies - not waters downstream of those unless the project extends there. You
may enter up to 3 waterbodies if needed.
15a. Receiving Mill Branch
Wate rbody* Nacre of waterbody into which storrrwater runoff w ill discharge
15b. Waterbody 27-43-15-12
Index No. * NC Waterbody Index Minter
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project r Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B. ^
F2rnittee Inforrration - Legally Fbsponsible Entity and Individual
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form should be the same person as listed in THIS SECTION, or an authorized responsible individual within the same
organization. That person must be a responsible corporate officer who owns or operates the construction activity, such
as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV,
Section B, Item (6) of the NCG010000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item (6) of that permit.
1. Organization Circle K Stores Inc
Name * If pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name* Meredith
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Rice
If Corporation, enter Faegistered Agent Last Wre
3b. Title Vice President
4. Permitee E-mail [e-mail]
Address *
5. Permittee 9197746700
Telephone No.*
6. Permittee Mailing Street Address
Address* 1100 Situs Court, Ste 100
Address Line 2
City State / Ftovince / Faegion
Raleigh NC
Fbstal / Zip Code Country
27606 USA
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
1100 Situs Court, Ste 100
Address Line 2
City
State / Ffovince / Fbgion
Raleigh
NC
Flostal / Zip Code
Country
27606
USA
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Wes
Contact - First
Name *
2. Primary Site
Williams
Contact - Last
Name *
3. Title
Construction Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
9195561714
Telephone No.
6. Organization
Circle K Stores Inc
Name
7. Site Contact
Street Address
Mailing Address*
1100 Situs Court, Ste 100
Address Line 2
city
Raleigh
Fbstal / Zip Code
27606
8. Consultant Name
(Optional)
Brian Downs
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
9198664504
Telephone No.
State / Rovince / Region
NC
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 03/11/2020
Approved *
2. E&SC Plan Project JC# 19-142-P
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Johnston County
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application. For linear projects, please also upload a site map showing the overall extent of the project or
include the beginning point and end point coordinates in the "Notes" box below.
5. E&SC Plan 19-142 Circle K ESC appr 3.11.2020.pdf 94.93KB
Approval letter or Mist beRDFformat
Grading Permit
Site Map (Optional) Helpful for linear project review
[1] C0.0 COVER SHEET.pdf 2.24MB
Mast be RDFforml
Notes (Optional) Rovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies for linear projects if necessary.
6. NOI Certification NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form 85.76KB
SW - SIGNED.pdf
Mast be FDFfon-rat
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed or required to be maintained under this Article or a rule implementing this Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Amide or rules of the
Commission implementing this Atcle shall be guilty ofa Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
17 I am the person responsible for the construction activities of this project, for
satisfying the requirements of this permit, and for any civil or criminal penalties
incurred due to violations of this permit.
rJ The information submitted in this NOI is, to the best of my knowledge and belief,
true, accurate, and complete based on my inquiry of the person or persons who
manage the system, or those persons directly responsible for gathering the
information.
* 17 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part II (Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit. I will nonetheless ensure that all conditions of Part
II of the permit are met on the project at all times.
* 17 I hereby request coverage under the NCG010000 General Permit and
understand that coverage under this permit will constitute the permit
requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Specify if you are:* r The Responsible Person named on this Notice of Intent
f Authorized Responsible Person*
Important: The person who electronically signs this Certification above must be the same person who signs the NOI
Certification Form. If that person is signing on behalf of the Permittee, that individual must be an authorized responsible
person within the same organization as the Permittee. *An authorized individual is a responsible corporate officer who
owns or operates the construction activity, such as a president, secretary, treasurer, or vice president, or a manager
that is authorized in accordance with Part IV, Section B, Item (6) of the NCG010000 General Permit. For more
information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
Signature
Type Name* Meredith W. Rice, Jr.
Title Vice President
Organization Circle K Stores, Inc.
Date * 03/26/2020

F. Tracking and COC Info
NOI Tracking No. 23698
NC Reference No. NCG01-2020-1248
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201248
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1248
Sequential number for submittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)